Overview

The National Institute of Mental Health (NIMH) convened its eleventh meeting of the Alliance for Research Progress (Alliance) on Friday, July 31, 2009 in Bethesda, Maryland; this document provides an overview of the proceedings. Alliance meetings serve as opportunities for participants to hear about exciting new research and advances in the field, to network with colleagues, and to interact directly with the NIMH director, Thomas Insel, M.D., and senior NIMH staff. Invitees included leaders from national voluntary organizations representing patients and their families. At this Alliance meeting, presentations focused on health care reform and comparative effectiveness research, mental health and the media, and mental health prevention research. For more information on the speakers, please see the attached agenda and roster of participants.

Major Themes

State of the NIMH Dr. Insel welcomed participants and presented an update on the State of the NIMH that focused on the NIMH Strategic Plan, the American Recovery and Reinvestment Act (ARRA or the Recovery Act), and new initiatives. He announced several new leadership appointments: Deputy Director, Philip Wang, M.D., Dr.P.H; Scientific Director, Richard Nakamura, Ph.D.; and, Office of Special Populations Director, Pamela Collins, M.D., M.P.H. Dr. Insel explained that NIMH’s new Strategic Plan is a vehicle to facilitate priority setting, rapid exploitation of new scientific opportunities, and monitoring the public health impact of NIMH research. He briefly discussed the burden of mental illness on society with regard to mortality rates and the loss of productivity. He reviewed the four strategic objectives of the Plan and discussed how the 4 P’s were associated with the document: Strategic Objective 1 focuses on the pathophysiology of mental illnesses; Objective 2 focuses on developmental trajectories of mental illnesses and predictive risk factors; Objective 3 focuses on preemptive and personalized interventions; and Objective 4 addresses the public health impact and participatory nature of research.

Dr. Insel discussed how ARRA funds will be used to jumpstart the NIMH Strategic Plan. He talked about the $10 billion appropriated to NIH through ARRA and how NIMH intends to use the $366 million of that sum appropriated directly to the Institute to stimulate the economy, create and preserve jobs, and advance biomedical research. He noted the increased level of reporting and accountability associated with the use of ARRA funds. To achieve the goals of ARRA, the Institute will accelerate biomedical research in these ways:

Expanding the payline to fund additional meritorious grants that have already been peer reviewed and approved by the National Advisory Mental Health Council (Council)

Expanding science by funding administrative and competitive revision supplements to existing grants and targeted Funding Opportunity Announcements including one on autism, and by funding new NIH-wide ARRA programs such as Challenge Grants and Grand Opportunity Grants.

Dr. Insel told Alliance members about NIMH comparative effectiveness research projects and signature projects associated with ARRA, including Reducing Suicidality in the U.S. Army and Recovery After an Initial Schizophrenic Episode (RAISE). He mentioned six new initiatives that will focus on diversity programs, an anti-stigma campaign, research domain criteria (RDoC), a Council workgroup on interventions, outreach to students in grades K-12 with the Society of Neuroscience, and mentoring networks to enhance diversity. Mark Chavez, Ph.D. and Nancy Desmond, Ph.D. presented concept clearances on the last two initiatives, respectively, which were voted on and approved by Alliance members.

Comparative Effectiveness Research (CER) Mark McClellan, M.D., Ph.D., Director of the Engelberg Center for Health Care Reform at The Brookings Institution and former Administrator of the Centers for Medicare and Medicaid Services, and former Commissioner of the Food and Drug Administration, talked with Alliance members about current issues related to the development of health care reform policy and comparative effectiveness research. He noted that a bipartisan approach to health care reform is a complex issue and discussed his work with the Bipartisan Policy Center (BPC, www.bipartisanpolicy.org), a group that includes former Senate Majority Leaders. Dr. McClellan highlighted four elements of a framework for health care reform developed by the BPC:

Reform the delivery system to provide high quality care. He noted that the report emphasized the importance of improving care while being aware of costs, and the need for accountability.

Identify and address gaps in payment reform. Dr. McClellan discussed the need to transition from a fee-for-service system to a performance-based system that uses accountability measures to encourage providers to work together to coordinate care inside and outside of the health care system.

Move toward a national program that will include some version of a requirement or mandate, some version of entitlement coverage, and accountability in the financial resources associated with the program (i.e., new taxes or funding changes to the Medicare or Medicaid programs).

Restructure the program to help those who do not have insurance coverage. He explained that this element is not a recommendation to replace Medicare and Medicaid, but rather to have some form of insurance in place for those who are working but have no coverage.

Dr. McClellan talked about his work on CER with the Institute of Medicine and other groups. He told Alliance members that there are concerns about CER being done incorrectly and leading to the rationing of care and services. He spoke about the need for better evidence this research can be supported by the $1.1 billion ARRA funds allocated. He discussed three key issues regarding CER:

The need for a federal entity to identify the essential areas for which research funding should be dedicated to address specific research priorities and questions

Translation of evidence from research findings and training into guidance for clinical practice

Identification or development of a system for determining how the findings from CER are used to make health care policy and coverage decisions

Dr. McClellan said that accountability measures and quality metrics for mental illnesses are lacking from the discussions about health care reform. Alliance members inquired about the best ways to include mental illnesses in the discussions about health care reform and CER. In closing, Dr. McClellan stated that more leadership is needed from the mental health community to help guide the process of health care reform and CER, and he encouraged the Alliance to work cooperatively to ensure that mental health is included in any discussions or policy that is developed.

Mental Health and the Media Joanne Silberner, M.A., correspondent at the health policy desk at National Public Radio talked with Alliance members about interacting with the news media to disseminate health information. She discussed the changing level of expertise in the field of journalism as a result of new and emerging technology, such as blogs, and noted that many senior writers are being replaced by younger and less experienced journalists. Ms. Silberner highlighted the types of stories of interest to the media including tragedy and success stories. She provided examples of good health care reporting and focused on the benefits and responsibility of patient and family groups, as well as advocacy organizations, to establish relationships with the media. It is essential that they work to provide the media with accurate health information to ensure that they “get the story right.” These organizations must be reliable sources for journalists when they need information on disease-specific topics.

Ms. Silberner provided Alliance members with helpful hints on how to effectively interact with the media. Highlighted hints include:

Identify whom you are talking to when you are contacted by a reporter. Make sure that the reporter clearly identifies him or herself and their organization. Ask about their target audience.

Have statements in response to issues prepared in advance. This ensures that the proper information is transferred to the media and that individuals are quoted correctly.

When possible, provide the media with background information on a topic or leads they can research. Ms. Silberner noted that journalists enjoy getting out of the office to experience a situation.

During the discussion period, Alliance members noted how helpful Ms. Silberner’s presentation was to them and their communication directors. Questions focused on how organizations could elevate public interest and news coverage on their respective disease areas. In conclusion, Ms. Silberner encouraged participants to contact her office to introduce themselves and provide contact information to assist NPR in following up on disease-related inquiries.

Mental Health Prevention Research E. Jane Costello, Ph.D., Director of the Center for Developmental Epidemiology at Duke University School of Medicine talked to Alliance members about prevention research and her work on The Institute of Medicine (IOM) report entitled “Preventing Mental, Emotional, and Behavioral Disorders in Young People” (http://www.nap.edu). Her presentation focused on what can be learned from the epidemiology of mental illness as it relates to prevention, and what types of interventions work best in certain settings. She discussed four points learned from the epidemiology of mental illness:

Mental illnesses are common and costly, with many beginning before age 21. Costs are high in terms of treatment and productivity, as well as those incurred by society and family members.

Preventive opportunities exist for early onset disorders; however, mental illnesses often co-occur, and it is difficult to prevent, diagnose, or treat multiple disorders at once.

Treatment for childhood illnesses is inaccessible to many families, even though early prevention and treatment can prevent adult disorders.

Preventive intervention, like treatment, is a scientific test of a causal hypothesis; therefore, these interventions should not be limited on the basis of economic, humanitarian, or scientific reasons.

Dr. Costello also cited examples from the IOM report of interventions that are effective in reducing psychiatric disorders at various developmental periods. She also highlighted two types of preventive interventions: universal and targeted. She told Alliance members that universal interventions are those programs that do not require potentially expensive screening and may have benefits beyond an identified outcome (i.e., fluoridation of drinking water). She explained that targeted interventions are programs that do not spend resources on people who do not need them or need them minimally, by screening for people who would benefit most from the intervention. Unfortunately, these interventions may also label certain groups as being high risk. In closing, Dr. Costello highlighted her research on the Great Smokey Mountain Study, which supported the use of early prevention interventions to prevent or reduce adult mental disorders.